IPEG Guidelines for Appendectomy

November 1, 2008

PREAMBLE

The laparoscopic approach to appendectomy in children has gained wide spread acceptance over the last 10 years. Advantages include improved diagnostic accuracy and decreased wound complication rate, when compared to the open procedure. However, its use in the management of complicated appendicitis is somewhat controversial. The following guideline provides recommendations to surgeons for the laparoscopic management of pediatric patients with appendicitis.

DISCLAIMER

Clinical practice guidelines are intended to indicate the best available approach to medical conditions as established by systematic review of available data and expert opinion. The approach suggested may not necessarily be the only acceptable approach given the complexity of the health care environment. These guidelines are intended to be flexible, as the physician must always choose the approach best suited to the individual patient and variables in existence at the moment of decision. These guidelines are applicable to all physicians who are appropriately credentialed and address the clinical situation in question, regardless of specialty.

Guidelines are developed under the auspices of the International Pediatric Endosurgery Group Surgeons and its various committees, and approved by the Executive Committee. Each guideline is developed with a systematic approach, and includes review of the available literature and expert opinion when published data alone are insufficient to make recommendations. All guidelines undergo appropriate multidisciplinary review prior to publication, and recommendations are considered valid at the time of publication. Because new developments in medical research and practice can change recommendations, all guidelines undergo scheduled, periodic review to reflect any changes. The systematic development process of clinical practice guidelines began in 2007, and will be applied to all revisions as they come up for scheduled review, as well as all new guidelines.

INTRODUCTION

Acute appendicitis is one of the most common intra-abdominal surgical procedures performed in children, especially in adolescents and teens. In the United States, about 7% – 8% of the general population develops acute appendicitis and requires surgical intervention at some point in their lifetime (1). Depending on the pathology of the appendix, acute appendicitis can be further divided into either simple or complicated appendicitis, with perforation and/or abscess formation occurring in the latter. Although the condition is relatively uncommon during infancy and early childhood, there is a disproportionately higher incidence of complicated appendicitis in this age group potentially due to difficulties in establishing an early diagnosis.

The surgical treatment of acute appendicitis has evolved over the past few decades. While surgery remains the most generally accepted treatment for simple acute appendicitis, the management for complicated disease, namely perforated appendicitis and appendiceal mass, has been controversial for decades (2-8). Advocates for initial non-surgical treatment with fluid resuscitation and intravenous antibiotics followed by interval appendectomy have shown the benefits of reducing major complications, fewer wound infections and shortening the hospital stay as well as decreasing the overall cost of treatment, (2,4,6) although the need for interval appendectomy at 2-3 months following medical management remains another debatable issue (9,10). The success of non-operative treatment of complicated appendicitis has stimulated some investigators to consider treatment of uncomplicated appendicitis with antibiotics. A recent study in adult men revealed an 86% success rate with antibiotics alone with a recurrence rate of 14% (38).

Right lower quadrant abdominal incisions have stood as the gold standard approach for appendectomy for decades. In recent years, laparoscopic appendectomy has gained wide popularity and has been shown to improve patients’ outcome in multiple reports (12-20). It seems reasonable that the laparoscopic appendectomy should be considered at least equivalent to open surgery in today’s laparoscopic era.

DEFINITION

Appendectomy can be simply defined as surgical resection of the appendix. While it is usually done in an urgent setting for a patient with acute appendicitis, recent studies have demonstrated no deleterious effect to a period of hydration and antibiotics of up to 24 hours prior to appendectomy (21-23). In contrast, interval appendectomy is performed in an elective setting after the acute inflammatory condition has subsided. The procedure usually follows successful medical treatment for complicated appendicitis.

DIAGNOSISThe need for appendectomy is usually based on the diagnosis of acute appendicitis which is made on clinical grounds in most cases. Localized peritonitis in the right lower quadrant of abdomen with the typical history, strongly suggests the diagnosis. In the past, ultrasonography or CT scan has proven to be an effective diagnostic aid in equivocal cases (24). Recent studies have suggested that routine use of imaging studies can reduce the negative appendectomy rate to 2-3% without increasing the perforation rate (39,40) Complicated appendicitis occurs as a result of perforated appendix with or without abscess formation. As a result, physical findings may reveal diffuse peritonitis or a tender right lower quadrant mass, which is due to an organized abscess. It is more common to have diffuse peritonitis in young children probably because of less omental fat to isolate the infection. Older children are more likely to have an appendiceal abscess. However, simple appendicitis may not always be differentiated from complicated cases prior to surgery. Diagnostic laparoscopy and appendectomy can be employed when the preoperative diagnosis of appendicitis is uncertain.

MANAGEMENT

The initial therapy for acute appendicitis is intravenous fluid and antibiotic administration. Subsequently, appendectomy is performed. If there is clinical and/or radiological evidence to suggest complicated appendicitis, the management is either surgery or non-operative treatment depending on the practitioner’s preference. Non-operative treatment consists of fluid replacement, intravenous antibiotics and analgesics. Percutaneous drainage of an appendiceal abscess may be indicated in selected cases. Choice of antibiotics may vary. For non-operative therapy, the antibiotics are typically continued for an arbitrary prescribed amount of time, usually 10-14 days. Interval appendectomy is usually performed after 2-3 months.

SURGICAL TREATMENT

Preoperative Workup
Appendicitis remains a clinical diagnosis, and operation can proceed with a consistent history and physical examination alone. Antibiotics are given before surgery. If a laparoscopic approach is to be used, the urinary bladder needs to be emptied prior to the procedure either by credé manuever or an indwelling catheter. Further work-up including blood tests, urinalysis, etc. are performed when clinically indicated.

Indications for Surgery
Appendectomy is indicated for patients with the clinical diagnosis of acute appendicitis. Interval appendectomy in an elective setting may be considered for patients with history of complicated appendicitis adequately treated with a nonoperative approach.

Surgical Techniques
Since the classic description by McBurney (11), surgeons have largely employed either a transverse or oblique right lower quadrant incision for appendectomy. Abdominal muscles are split. The mesoappendix is divided before the appendix is excised at the base. Management of the appendiceal stump varies from simple ligation, ligation with inversion using a pursestring, to inversion without ligature, depending on the surgeon’s preference.

Laparoscopic Appendectomy
In 1983, Semm described the first case of laparoscopic appendectomy, which was done as an incidental procedure during a pelvic exploration.25 However, laparoscopic appendectomy had not gained wide popularity until the emergence of laparoscopic cholecystectomy which started a revolution. Subsequent controlled studies as well as meta-analysis in adult population demonstrated the advantages of laparoscopic appendectomy including fewer wound infections, faster return to normal activities and decreased length of hospitalization (12-15).

In the early 1990s, a French group reported their large series of laparoscopic appendectomy in children and established that this procedure was a reasonable alternative in the treatment of appendicitis in paediatric population (17,18). The reported advantages of laparoscopic appendectomy, compared to open surgery, in children are similar to that of adult and include shorter hospitalization, fewer wound infections, earlier return to normal activities, better cosmesis, more effective lavage and better visualization of the peritoneal cavity (16-18,20,26-28).

What seems to be more controversial is its application in complicated appendicitis. The concern for greater incidence of intraabdominal abscess following the laparoscopic approach was reported in some studies (29-31) but not supported by others (27,28). Using nonoperative treatment for complicated appendicitis followed by interval laparoscopic appendectomy obviates the need to manage the inflammatory situation in the acute stage. Such a policy has been shown to be successful in treating most of the cases of complicated appendicitis with shorter hospitalisation, lower charges and less morbidity (6,8,19). Small bowel obstruction is reported to be a sign which suggests failure of nonsurgical treatment and necessitates early surgery (6,19). Using the laparoscopic approach for interval appendectomy has been shown to have the advantages of minimal morbidity and very short hospital stay (32,33). The operating time is similar to the open procedure and can be done on outpatient basis (33).

Laparoscopic Techniques
Laparoscopic appendectomy usually involves a 3-trocar technique. A 10-12mm cannula is usually placed in the umbilicus to allow the passage of the telescope, a stapler (if used) and the retrieval of the appendix. Two 3 mm or 5mm cannulae are then placed below the bikini line in the left lower quadrant and midline immediately over the pubis (34,35). The telescope is often placed through the left lower quadrant port, in-line with the appendix. Endoscopic clips, endoscopic stapler or thermocoagulating device can be used for division of the mesoappendix (17,18,35-37) The base of the appendix can be ligated inside the abdomen with endoloops, endoscopic sutures or stapler, or can be secured extracorporeally with the appendix drawn out through a 5mm cannula at the right lower quadrant (17,18,35-37). Whenever possible, the appendix should be extracted through the umbilical cannula to avoid direct contact with the wound. At times, the appendix can be too thick to be removed through the cannula and it should then be placed in a retrieval bag, which is withdrawn through the port site.

SUMMARY

Appendectomy is one of the most common surgical procedures in children. The laparoscopic approach, which can be applied in acute appendicitis or in an elective setting as interval appendectomy, carries similar safety and effectiveness as open surgery.

WHEN IPEG WAS FOUNDED IN 1991, OUR GOALS WERE SIMPLE:
To assure that all pediatric surgeons, pediatric urologists and general surgeons who treat children have access to current information defining the best, least invasive surgical treatment.
To encourage development and evaluation of those treatments through peer-to-peer communication, education, and research.
WHO IS … Read More »